double-outlet right ventricle; LAO, left anterior oblique; LV, left ventricle; LVOT, left

ventricular outflow tract; PA, pulmonary artery; PDA, patent ductus arteriosus; PFO, patent
foramen ovale; (P) PS, (peripheral) pulmonary stenosis; RAO, right anterior oblique; RV, right
ventricle; TGA, transposition of the great arteries (L, left; D, right); TOF, tetralogy of Fallot;
VSD, ventricular septal defect.

Common Operations
ASD OS closure
Under GA & Supine position. Parts are painted &Draped. Chest opened
through Median sternotomy. Hemostasis achieved. Thymus removed.
Pericardium opened towards the rt. Side & stays put. Anatomy assessed.
Looked for LSVC & Rt. PAPVC.Systemic heparinisation done with 3-5mg/Kg
Heparin.Aortic & caval purstrings taken.Cardioplegia purstrings
taken.Cannulated with Aortic & two caval cannulae. Once ACT crossed 480
seconds went on CPB. Cardioplegia cannula put. Cavae looped & SVC snugged.
Aorta was cross clamped. Patient was cooled to 28 degree centigrade. Cold
blood antegrade cardioplegia used (20ml/kg). IVC snugged & RA opened
obliquely. Stays put on RA. Anatomy assessed. Mitral & tricuspid valve
checked for regurgitation. Pericardium was harvested as per the size of ASD. 4-
0/5-0 Polypropylene suture taken & 1st suture passed through the septum at
the 50 clock position & suturing was done towards the surgeon till upper edge
of the ASD. Reawarming started. Now the other end of the suture is used &
closure of the remaining part of the ASD done. Deairing of the left heart done
by asking anaesthetist to ventilate & hold the breath. Root vent connected,
trendlenberg position put. Cross clamped released. RA closed with 5-0
polypropylene suture. Right heart deaired after clamping the IVC cannulae&
releasing the snugger. Heart started beating into SR spontaneously. Came off
CPB gradually.Decannulated.Protamine given. Hemostasis achieved.

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Pericardium closed over the heart. Pacing wire put. Pericardial & mediastinal
chest drains put. Sternum & chest closed in layers.
ASD OP Repair
Kirklins Technique
After median sternotomy, the pericardium was cut on rt. side & stayed. After
heparinising the patient, the purse string sutures were taken around the aorta;
proposed site for ante plegia cannula, SVC & IVC.The SVC was looped around.
The aorta was cannulated. The SVC & IVC were cannulated with angled
cannulae. Established standard CPB. Went around the IVC after dissecting
around & looped it. Ante plegia cannula put. Patient cooled. SVC snared. Cross
clamped & gave antegrade blood cardioplegia. Snared the IVC & opened the
RA. The ASD was visualized. After satisfactory arrest the RA margins were fixed
with silk stays. The ASD margin was retracted & the Mitral valve was
visualized. It was found to be as described. The cleft in the Mitral valve was
sutured with four separate interrupted 5-0 prolene sutures. There was trivial
MR after repair. The OPASD was closed with untreated autologous pericardial
patch keeping the Coronary sinus on the LA side. The patient was rewarmed.
The left heart was deaired through PFO. With head end down with root vent
connected & on, declamped & defibrillated into SR. RA closed on beating heart.
Came off CPB without support.Decannulated in stages. Mediastinal
&pericardial tubes put. After verifying the counts chest was closed after
satisfactory hemostasis. Shifted to ICU with stable hemodynamics & connected
to the ventilator.
McGoons Technique
After median sternotomy, the pericardium was cut on rt. side & stayed. After
heparinising the patient, the purse string sutures were taken around the aorta;
proposed site for ante plegia cannula, SVC & IVC.The SVC was looped around.
The aorta was cannulated. The SVC & IVC were cannulated with angled
cannulae. Established standard CPB. Went around the IVC after dissecting
around & looped it. Ante plegia cannula put. Patient cooled. SVC snared. Cross
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clamped & gave antegrade blood cardioplegia. Snared the IVC & opened the
RA. The ASD was visualized. After satisfactory arrest the RA margins were fixed
with silk stays. The ASD margin was retracted & the Mitral valve was
visualized. It was found to be as described. The cleft in the Mitral valve was
sutured with four separate interrupted 5-0 prolene sutures. There was trivial
MR after repair. The OPASD was closed with untreated autologous pericardial
patch keeping the Coronary sinus on the RA side. The patient was rewarmed.
The left heart was deaired through PFO. With head end down with root vent
connected & on, declamped & defibrillated into SR. RA closed on beating heart.
Came off CPB without support.Decannulated in stages. Mediastinal &
pericardial tubes put. After verifying the counts chest was closed after
satisfactory hemostasis. Shifted to ICU with stable hemodynamics & connected
to the ventilator.
ASD SV Repair
Double patch technique
Under GA,chest painted and draped, median sternotomy was done,
pericardium was opened to the right after dissecting the thymus, Stays taken,
patient was heparinised,went on to CPB aortic, SVC & IVC cannulae.Cooled to
28 deg celicius,aorta was cross clamped, cold antegrade cardioplegia was used
to arrest the heart with surface ice slush to cool the myocardium. With good
arrest the cavae snugged, RA was opened through posterior vertical incision
and stays taken. SV type of ASD was enlarged towards the septum secundum
& margins endothelialized.ASD SV closed with rerouting of RSPV & RMPV into
LA using autologous untreated pericardial patch using 5-0 prolene sutures.
Patient was rewarmed, left heart was deaired with head end steep down with
aortic root vent on and cross clamp released. RA was closed & SVC was
enlarged with autologous untreated pericardial patch. Came off CPB. Heparin
was reversed, decannulated, after obtaining satisfactory haemostasis the
sternotomy was closed in layers with chest tubes & pacing wires .Shifted to
ICU with stable haemodynamics.
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Single patch Technique
Under GA,chest painted and draped, median sternotomy was
done, pericardium was opened to the right after dissecting the thymus, Stays
taken, patient was heparinised, went on to CPB with aortic, RAA straight &
IVC angled venous cannulae. Cooled to 30 deg Celsius, aorta was cross
clamped; cold antegrade cardioplegia was used to arrest the heart with surface
ice slush to cool the myocardium. With good arrest the cavae snugged, SVC-RA
junction was opened through vertical incision. ASD SV closed with rerouting of
RSPV & RMPV into LA using autologous untreated pericardial patch using 5-0
prolene sutures by single patch technique. Patient was rewarmed, left heart
was deaired with head end steep down with aortic root vent on and cross clamp
released. Came off CPB. Heparin was reversed, decannulated, after obtaining
satisfactory haemostasis the sternotomy was closed in layers with chest tubes.
Shifted to ICU with stable haemodynamics.
Closed Mitral Valvotomy
Under GA patient was positioned in the right lateral, part painted and draped,
chest entered through left anterolateral throacotomy through 5th ICS.
Pericardial was opened anterior to the phrenic nerve & stays taken. LV apical
purstring suture taken using 2-0 silk & controlled ventriculotomy was done,
purse string sutures were taken on the LAA. LAA was calmped using satinsky
clamp & opened the LAA. Opening extended using potts scissor. Index finger of
the rt. Hand inserted in the opening of LAA. Ask assistant to remove the clamp.
The MV felt at both commissures & MR assessed. Tubbs dilator inserted
through ventriculotomy. The tip of the Tubbs dilator passed across the MV
opening. If opening is small finger fracture technique to be used to widen the
mitral valve opening. Tubbs dilator placed across the maitral valve & opened
against the leaflet/ perpendicular to commissures. Dilatation to be done
gradually. Tubbs dilator removed & Silk suture with snugger tightened. Assess
MV for opening, Subvalvar pathology & MR. Finger is removed from the LAA
with the remaining 3 fingers pressing against the LAA. The purstring suture
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tied. Reinforcing suture over LAA put. LV opening closed with 4-0 prolene
suture & silk purstring tied. Pericardium washed with plenty of normal saline
& Pericardium was approximated. After obtaining satisfactory haemostasis, the
thoracotomy was closed in layers with ICD tube and shifted to ICU with stable
haemodynamics in NSR.
Mitral Valve Replacement
Under GA chest was opened by median sternotomy incision. Pericardium
opened & stayed. Purse string sutures were taken over the aorta, RAA /SVC
and inferior venacavae. After heparinisation the vessels were cannulated.
Went on CPB. Patient was cooled up to 28 Deg cels. Cross clamped the aorta &
started cold antegrade plegia . The Waterston groove was dissected & LA was
stabbed. After satisfactory arrest, the LA was opened. MV was assessed. The
AML was caught with Vulsalum/ Allis forcep/ Silk stay suture. Incision made
on AML at 12 Oclock position. Incision was extended on both the side. Valve
was excised & replaced with 29M St. Jude bileaflet prosthetic valve using 2-0
Ethibond interrupted pledgetted sutures. Valve was checked for opening &
closing. A Foley catheter put across the valve. All sutures cut. Saline wash
given.LA closed directly after deairing & Foley catheter removed.
Rewarmed.Declamped & defibrillated .Came off CPB. After satisfactory
hemostasis, chest tubes were put. Pericardium was closed .Chest closed in
layers after verifying the counts. Shifted to ICU.
Aortic Valve Replacement
Under GA, part painted and draped, median sternotomy done, thymus divided
in the midline, pericardium opened in the midline and marsupialised, Aortic
and RAA purse string sutures were taken,heparinised and went onto CPB with
aortic & two stage venous cannulae,LV vented through RSPV,Core cooled to 28
degree C, aorta was cross clamped, retrograde cold blood cardioplegia was
started and aorta was opened with reverse hockey stick incision about 1.5-1.75
cms above the RCA origin and stays taken, direct ostial antegrade cold blood
cardioplegia was delivered to both the coronaries, Topical ice slush was applied
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to further cool the myocardium ,After obtaining satisfactory arrest, the aortic
valve was excised . The root & cavity were thoroughly washed. Aortic annulus
sized. The valve was taken & ,2-0 Polyester interrupted pledgetted sutures were
passed along the annulus and passed through the valve ring, parachuted and
tied, Valve checked for opening & closing.Aortotomy was closed using no.4`0
prolene suture, Rewarmed,aortic cross clamp was released with head end steep
down with aortic root and LV vent on, defibrillated, Gradually came off CPB in
SR,Heparin was reversed,decannulated in stages, After obtaining satisfactory
hemostasis, chest drains were placed, one ventricular pacing wire put,
Pericardium approximated loosely throughout, Chest closed in layers, Shifted
to ICU with stable hemodynamics and electively ventilated.
MVR & AVR (DVR)
Under GA & supine position, Parts painted & draped. Median sternotomy done,
Pericardium opened, Purstring sutures taken over Aorta, SVC /RAA & IVC.
After systemic heparinisation, went into CPB after cannulating the aorta, SVC
& IVC. Core cooled, cross clamped & stabbed the LA. Opened the aorta & gave
direct coronary osteal plegia. After satisfactory arrest, the aortic valve was
assessed & excised. The sutures were taken & driven through the prosthetic
valve but the valve was not lowered.
Next, the LA was opened fully, mitral valve assessed. It was excised & replaced
with prosthetic mitral valve using interrupted pledgetted sutures. Next, the
aortic valve was lowered & the sutures tightened & tied so as to fix the aortic
valve. The aorta was next closed in two layers of continuous Prolene.
Rewarmed. Foley's catheter put through the mitral valve while LA was closed
with continuous Prolene. The heart was declamped with root vent on.
Defibrillated. LA vented. Later Foleys catheter removed & suture line tightened
& tied. Came off CPB.Decannulated in stages. Chest tubes put. Counts verified.
Chest closed in layers. Shifted to ICU with stable hemodynamics & connected
to ventilator.

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VSD Closure
Under GA, patient positioned, part painted and draped, median sternotomy
done, thymus divided in the midline, right lobe of the thymus excised,
pericardium opened in the midline and marsupialised, Aortic, SVC and IVC
purse string sutures were taken, heparinised and went on to CPB with aortic ,
SVC and No IVC straight venous cannulae, Core cooled to 28 degree C, aorta
cross clamped, root cold blood cardioplegia was delivered ,SVC and IVC were
snugged and RA opened and stays taken, LA/LV vented through PFO, After
obtaining satisfactory arrest, VSD was closed with Dacron patch using
interrupted pledgetted prolene ,
Suturing for various types of VSDs
1) PM/SA VSDs- Start from the base of tricuspid valve. Transition from
valve to ventricular septum about 0.5-1.0 cm below the VSD margin.
2) SP/DC VSD- Approach through MPA. Start from Centre of VSD at septal
level. Come on both side up till you reach pulmonary valve. Pass part of
the sutures through pulmonary annulus.
3) MM/Inlet Muscular VSD- Start from the base of tricuspid valve,
Transition 0.5cm below the VSD margin. Care to be taken at upper
margin of VSD as conduction runs there.
PFO was closed directly, Rewarmed, left heart was deaired through aortic root
vent on with head end steep down and aortic cross clamp was released,
Defibrillated. RA was closed using no. 5`0 prolene suture, Came off CPB,
Heparin was reversed and decannulated in stages, pacing wires placed, chest
drains were placed, pericardium was loosely approximated throughout, After
obtaining satisfactory haemostasis, chest was closed in layers, Shifted to ICU
with stable haemodynamics and electively ventilated.

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TOF Correction

Trans RA without TAP:

Under GA & Supine position, parts painted & drapped.After median
sternotomy, the pericardium was opened towards right & stays put
.Cannulated the aorta, SVC, & IVC. MPA was dissected from the aorta. SVC &
IVC looped. Antegrade plegia cannula put. After heparinisation went on CPB.
Core cooled to 28 Deg C .Cross clamped the aorta. Gave antegrade cold blood
cardioplegia with topical ice-slush to cool the heart. After satisfactory arrest,
cavae snugged & RA opened. LV vented through PFO. Anatomy assessed. The
RVOT was cored out from RA. Bands & bundles cut, starting at 1 Oclock
position. Avoid cutting TSM. The RVOT was sized with Hegars. The VSD was
closed through the RA using a Dacron patch with interrupted pledgetted
Prolene. Surgically created PFO closed directly after deairing the left heart.
Rewarmed.Declamped with root vent on with head end down. Heart started
beating. RA closed directly on beating heart. Came off CPB on
inotropes.Decannulated in stages. Chest tubes & pacing wire put. Chest closed
after verifying counts after satisfactory hemostasis. Shifted to ICU with stable
hemodynamics & connected to ventilator.
Trans RA & PA with TAP:
Under GA & Supine position, parts painted & drapped.After median
sternotomy, the pericardium was opened towards right & stays put
.Cannulated the aorta, SVC, & IVC. MPA was dissected from the aorta. SVC &
IVC looped. Antegrade plegia cannula put. After heparinisation went on
CPB.Core cooled to 28 Deg C .Cross clamped the aorta. Gave antegrade cold
blood cardioplegia with topical ice-slush to cool the heart. After satisfactory
arrest, cavae snugged & RA opened. LV vented through PFO. Anatomy
assessed. MPA opened vertically. The RVOT was cored out from RA& PA.
Bands & bundles cut, starting at 1 Oclock position from RA. Avoid cutting
TSM. Pulmonary valvotomy/valvectomy done. The RVOT was sized with
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Hegars. The VSD was closed through the RA using a Dacron patch with
interrupted pledgetted Prolene. RVOT & MPA augmented with autologous
pericardial transannular patch. Surgically created PFO closed directly after
deairing the left heart. Rewarmed.Declamped with root vent on with head end
down. Heart started beating. RA closed directly on beating heart. Came off CPB
on inotropes.Decannulated in stages. Chest tubes & pacing wire put. Chest
closed after verifying counts after satisfactory hemostasis. Shifted to ICU with
stable hemodynamics & connected to ventilator.
TAPVC Correction
Supracardiac TAPVC
Under GA, chest was painted and draped. Pericardium was opened to the right
after excising the thymus. Vertical vein dissected & looped doubly outside the
pericardium. Patient was heparinised. Went on to CPB with aortic, angled SVC
& IVC cannulae. LAA tip was ligated & suture kept on clamp to determine the
LAA base. Cooled to 28 degree celicius, aorta was cross clamped, cold
antegrade blood cardioplegia was used to arrest the heart with surface ice
slush used to cool the myocardium. Common Chamber stabbed near RA-CC
junction. The RA was opened by vertical incision. The incision extended across
the ASD into LA posterior wall till the base of LAA. Common chamber incision
was extended towards the left till the opening of left pulmonary veins. Anatomy
of all pulmonary veins assessed. Common chamber draining LPV& RPV
anastomosed with LA using prolene suture, The opening should be at least the
size of Mitral valve. ASD closed with autologous pericardium. Left heart
deaired at the end of ASD closure. VV ligated near its junction with innominate
vein. Declamped with root vent on & head end down. Defibrillated the heart.RA
closed on beating heart. Came off CPB. Pacing wire & chest tubes put. Chest
closed. Counts verified. After satisfactory hemostasis shifted to ICU with stable
haemodynamics.

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Pericardiectomy
Under GA & supine position, part painted and draped, median sternotomy,
thymus divided in the mid-line, Pericardium opened over the ascending aorta
and extended over RVOT, LV was released first over the inferior wall and lateral
wall, Dopamine started electively at 3 mics/Kg/mins .Densely adherent
pericardium over the RA, RVOT and over the inferior wall of the LV was slowly
and gradually debrided, SVC and IVC were fully released. Pericardium was
excised from right to left phrenic nerves& innominate vein to diaphragm. Both
pleura opened widely. After obtaining satisfactory haemostasis, chest drains
were placed, Chest closed in layers and shifted to ICU with stable
haemodynamics and electively ventilated.
PDA Ligation
Under GA & left lateral position. Chest opened by left posterolateral
thoracotomy. Mediastinal pleura over the aorta opened, Left superior
intercostals vein ligated & cut. Stays put on mediastinal pleura. PDA dissected
& looped around with silk. Under hypotensive anaesthesia, the PDA was ligated
doubly with no. 2 silk/Floss silk .After satisfactory hemostasis, the overlying
mediastinal pleura was closed. Chest tube was put. The chest was closed in
layers. Shifted to ICU with stable hemodynamics in SR.
PDA D/S
Under GA & left lateral position. Chest opened by left posterolateral
thoracotomy. Mediastinal pleura over the aorta dissected & stays taken. PDA
dissected & looped around with silk. PDA was clamped & divided & both ends
of the PDA sutured with 5-0 prolene suture. After satisfactory hemostasis, the
overlying mediastinal pleura were closed. Chest tube was put. The chest was
closed in layers. Shifted to ICU with stable hemodynamics in SR.
Coarctation Repair
Under GA & left lateral position. Chest opened by Left posterolateral
thoracotomy through the fourth space. The aorta was exposed after cutting &

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staying the overlying mediastinal pleura. The coarcted segment & the great
vessels identified, dissected around & looped. The intercostals were divided &
looped respectively. The aorta above & below the coarct was looped. After
systemic Heparinisation, the aortic arch proximal to the Coarctation was
clamped with a curved clamp proximal to LSCA, & the left subclavian was also
clamped with straight clamp. The aortic arch distal to the coarctated portion
was also clamped with a straight clamp. The PDA dissected looped & divided,
the end was sutured with 5-0 prolene suture. The Coarctation segment was
next excised leaving wide lumen of the aorta on either side. Both end s were
anastomosed with continuous prolene. The distal mean arterial pressure [as
measured by the Lt FA pressure-line always maintained around 35-40 mmHg
throughout the anastomoses]. After the anastomoses, the aortic clamps were
released one by one & satisfactory hemostasis ensured. Mediastinal pleura
were closed. Chest closed after verifying the counts & putting the chest tube.
Shifted to ICU in stable condition.

Cardiovascular Medications

Terminologies
1. Adrenergic: Norepinephrine as a neurotransmitter, Effect on cells of
Autonomic nervous system (ANS).
2. Cholinergic: Acetylcholine as a neurotransmitter, Effect on cells of
Autonomic nervous system (ANS).
3. Sympathomimetic: Sympathetic nervous system stimulant.
4. Sympatholytic: Sympathetic nervous system blocker.
5. Chronotropic: Affecting the Heart rate.
6. Inotropic: Affecting the force of myocardial contraction.
7. Dromotropic: Affecting the velocity of conduction.
Adrenergic receptors

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